J Manipulative Physiol Ther. 2009 (Jul); 32 (6): 431437 ~ FULL TEXT
Cheryl Hawk, DC, PhD, Jerrilyn Cambron, DC, PhD
Cleveland Chiropractic College,
Kansas City, Mo, USA.
OBJECTIVE: This study is part of an avenue of research exploring the effect of chiropractic care on balance in older adults. The purpose of this study was to (1) assess the use of the 7-item version of the Berg Balance Scale, (2) explore possible effects of an 8-week course of chiropractic care on balance as measured by the 7-item Short-Form Berg Balance Scale (SF-BBS) in adults 65 years or older with impaired balance, and (3) collect preliminary information on the possible relationships of dizziness and/or chronic pain to poor balance.
METHODS: This was a single-group, pretest/posttest design intervention study. Patients 65 years and older who could stand on one leg for less than 5 seconds were eligible. They received pragmatic chiropractic care for 16 visits for an 8-week period. Outcomes were assessed at baseline, visit 8 and visit 16 in terms of balance SF-BBS, dizziness (Dizziness Handicap Inventory [DHI]), chronic pain (Pain Disability Index), and depression (Geriatric Depression Scale).
RESULTS: Sixteen patients were enrolled; 14 completed the study. There was one mild and transient adverse effect, muscle soreness, which self-resolved. One patient was depressed, and his Geriatric Depression Scale score improved significantly during the study. Of the 6 patients with significant dizziness at baseline, 3 had scores of 0 (no dizziness) on the DHI at visit 16. Patients with dizziness tended to have greater chronic pain and show greater reductions in that pain than nondizzy patients. No clinically important effects on balance as measured by the SF-BBS were apparent for the group as a whole, although 3 individual patients improved by 4 to 6 points.
CONCLUSION: The Short-Form Berg Balance Scale (SF-BBS) did not show a great deal of clinical responsiveness in this study population. The outcome measures used for chronic pain (Pain Disability Index) and dizziness (DHI) appear to be appropriate for assessing patients in future larger studies for longer periods
From the FULL TEXT Article
Falls are an important public health concern, making major contributions to death, disability, and health care costs in older adults.  Because of the importance of fall prevention to the well-being of the aging population, as well the extremely high health care costs associated with falls, the evidence base on this topic is growing exponentially. At least 16 controlled studies have been done examining the contribution of various risk factors to falls.  Lower-extremity weakness, balance, and gait deficits are the top risk factors.  Interventions that target these have been shown to reduce risk of falls.
Although a great deal of research has addressed the effectiveness of chiropractic care, specifically spinal manipulation, for musculoskeletal complaints, especially back and neck pain, [3, 4] few studies have considered possible effects on gait and balance, which might be effected by improvements in pain and stiffness. Spinal manipulation has also been shown to have some benefit for certain types of dizziness, which is a common factor contributing to balance deficits in the elderly.  This study is part of an avenue of research beginning to explore the effect of chiropractic care on balance in older adults. 
The purpose of this study was to
(1) assess the use of the 7-item version of the BBS,
(2) explore possible effects of an 8-week course of chiropractic care on balance as measured by the 7-item SF-BBS in adults 65 years or older with impaired balance, and
(3) collect preliminary information on the possible relationships of dizziness and/or chronic pain to poor balance.
Limitations of the Study
There were several limitations to this study. First, we did not have a comparison group, so the amount of change due to natural history, attention, participation in a study, and other similar factors is unclear. Second, we have a small sample size, possibly biasing our results. Third, bias may have been present in performing the SF-BBS because there was no possibility of blinding in the study. Two different assessors performed the SF-BBS, although we attempted to minimize any possible inconsistency by training them together using explicit instructions for scoring. Fourth, self-report bias may have been present with the patient-completed outcomes (PDI, GDS, and DHI) again because blinding did not occur in this study. However, these measures have been documented to be both reliable and valid, when used in similar populations, so we feel that they are acceptable measures.
Finally, our sample had relatively healthy self-care habits, particularly exercise, possibly influencing the results. It is unusual for people older than 65 years to belong to a fitness center, perhaps because there are not many fitness centers that specifically cater to older adults, as does Fit for Life. A recent study showed that membership at a fitness center was associated with increased health promoting behaviors such as regular health care visits and proper nutrition. Interestingly, these behaviors were related to the club membership rather than increased physical activity.  It is possible that the patients in this study also had significantly better health promoting habits than the general population, thereby improving the expected results. Certainly, their reported levels of physical activity were above average; however, other reported health habits such as alcohol and medication use were similar to those of the general population, as was the prevalence of overweight. [26, 27]
Discussion of Study Objectives
The objectives of this study were to
(1) assess the use of the 7-item version of the BBS,
(2) explore possible effects of an 8-week course of chiropractic care on balance as measured by the SF-BBS in adults 65 years or older with impaired balance, and
(3) collect preliminary information on the possible relationships of dizziness and/or chronic pain to poor balance. How each of these objectives was met will be discussed below.
Assessment of the Use of the SF-BBS
The use of the SF-BBS in this study was disappointing. This may be due to the fact that this instrument was developed for poststroke patients, and so, its applicability to a different population of older adults may not be appropriate.  We found that only one of the 7 questions, standing on one leg, showed any change over the 16 visits. Because of this, the SF-BBS may not have a great deal of use as an outcome measure for future, similar studies, particularly when the participants are relatively high functioning at baseline. It is noteworthy that the changes in the SF-BBS had no apparent relationship to those in the OLST, perhaps because the SF-BBS used broad cateries and the OLST measured actual standing time. Our new study, currently underway, will compare the Timed-Up-and- Test to the SF-BBS and retain the use of the OLST, which is identical to the most responsive item on the SF-BBS, except that it measures time in seconds rather than in cateries.
Assess Possible Effects of an 8-Week Course of Chiropractic Care on Balance as Measured by the SF-BBS
No clinically important effects on balance as measured by the SF-BBS or the OLST were apparent for the group as a whole. However, 3 of the 14 patients improved at least 4 points on the SF-BBS, which may be clinically important, although no studies have yet determined the amount of change in SF-BBS scores that is clinically significant. It is possible that this initial sample of patients was already high functioning, given their unusually active lifestyle, and so, even though they could not stand on one leg very long, they may have been well adapted and less likely to fall, particularly for only a 2month period. Our new study is enrolling patients in an assisted living facility who are not regular exercisers to investigate a lower-functioning sample of older adults. We will also assess them for a longer period, increasing our ability to see a change in outcomes if they occur.
Assess Possible Relationships of Dizziness and/or Chronic Pain to Poor Balance
Our results showed a clinically significant reduction in pain and dizziness in the patients who indicated dizziness at baseline; however, no such change occurred in the nondizzy group. This may be because the patients with dizziness also had higher PDI scores at baseline, and so may have had more room for improvement. In this pilot study, there was no apparent relationship between improvements in either pain or dizziness with improvements in balance.
This might indicate
(1) that there is no such relationship,
(2) that the outcome measures for balance did not capture changes in balance, or
(3) that dizziness, being an episodic condition, might not have a constant impact on measures of balance.
We are currently completing a pilot study following 30 patients for 1 year and have included collection of real-time falls as an outcome measure in addition to intermediate measures such as the SF-BBS.
The SF-BBS did not show a great deal of clinical responsiveness in this study population. The outcome measures used for chronic pain (PDI) and dizziness (DHI) appear to be appropriate for assessing patients in future larger studies for longer periods.
Funding Sources and Potential Conflicts of Interest
This study was funded by Cleveland Chiropractic Clinic College, Kansas City, Mo. The authors report no conflicts of interest.
The authors thank the research coordinators Jennifer Bedard and Cathy Evans for organizing the processes of research and patient management for this study. The authors thank Kenneth R. Blom, President of Stratford Development Corporation, Raytown, MO, and Debra Wood-Fowler, Director of Fit for Life, Raytown, MO, for providing space to conduct treatment at the Fit for Life facility and for facilitating this study. They also thank Mark Pfefer, RN, DC, MS; Michael Ramcharan, DC; Richard Strunk, DC, MS; and Nathan Uhl, DC, for their clinical expertise and dedication in serving as research clinicians.
Kannus, P, Sievanen, H, Palvanen, M, Jarvinen, T, and Parkkari, J.
Prevention of falls and consequent injuries in elderly people.
Lancet. 2005; 366: 18851893
Falls in older people: epidemiology, risk factors and strategies for prevention.
Age Ageing. 2006; 35: ii37ii41
Bronfort, G, Haas, M, Evans, R, Kawchuk, G, and Dagenais, S.
Evidence-informed Management of Chronic Low Back Pain
with Spinal Manipulation and Mobilization
Spine J. 2008 (Jan); 8 (1): 213225
Hurwitz, EL, Carragee, EJ, van der Velde, G et al.
Treatment of Neck Pain: Noninvasive Interventions: Results of the Bone and Joint Decade
20002010 Task Force on Neck Pain and Its Associated Disorders
Spine (Phila Pa 1976). 2008 (Feb 15); 33 (4 Suppl): S123152
Reid S, Rivett D.
Manual Therapy Treatment of Cervicogenic Dizziness: A Systematic Review
Man Ther. 2005 (Feb); 10 (1): 413
Hawk C, Pfefer M, Strunk R, Ramcharan M, Uhl N.
Feasibility Study of Short-term Effects of Chiropractic Manipulation on Older Adults With Impaired Balance
Journal of Chiropractic Medicine 2007 (Dec); 6 (4): 121131
Hawk, C, Hyland, J, Rupert, R, Colonvega, M, and Hall, S.
Assessment of balance and risk for falls in a sample of community-dwelling adults aged 65 and older.
Chiropr Osteopat. 2006; 14: 313
Hawk, C, Rupert, R, Colonvega, M, Hall, S, Boyd, J, and Hyland, J.
Chiropractic care for older adults at risk for falls: a preliminary assessment.
J Am Chiropr Assoc. 2005; 42: 1018
Christensen, M, Kollasch, M, Ward, R, Webb, K, Day, A, and ZumBrunnen, J.
Job Analysis of Chiropractic 2005
NBCE, Greeley (Colo); 2005
Geriatric practice-specific issues.
in: S Haldeman (Ed.) Principles and practice of chiropractic. 3rd ed.
McGraw-Hill, New York; 2005: 10791098
National Institute on Aging.
Exercise: a guide from the National Institute on Aging.
The Associations, Bethesda; 2006 (Available from:)
(Accessed July 21, 2009)
Whitney, SL, Poole, JL, and Cass, SPA.
Review of balance instruments for older adults.
Am J Occup Ther. 1998; 52: 666671
Bogle-Thorbahn, L and Newton, R.
Use of the Berg balance test to predict falls in elderly persons.
Phys Ther. 1996; 76: 576583
Lajoie, Y and Gallagher, SP.
Predicting falls within the elderly community: comparison of postural sway, reaction time, the Berg balance scale and the Activities-specific Balance Confidence (ABC) scale for comparing fallers and non-fallers..
Arch Gerontol Geriatr. 2004; 38: 1126
Shumway-Cook, A, Brauer, S, and Woollacott, M.
Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test.
Phys Ther. 2000; 80: 896903
Chou, C, Chien, C, Hsueh, I, Sheu, C, Wang, C, and Hsieh, C.
Developing a short form of the Berg Balance Scale for people with stroke.
Phys Ther. 2006; 86: 195204
Atwater, S, Crowe, T, Deitz, J, and Richardson, P.
Interrater and test-retest reliability of two pediatric balance tests.
Phys Ther. 1990; : 7987
Drusini, AG, Eleazer, GP, Caiazzo, M et al.
One-leg standing balance and functional status in an elderly community-dwelling population in northeast Italy.
Aging Clin Exp Res. 2002; 14: 4246
Tait, RC, Chibnall, JT, and Krause, S.
The Pain Disability Index: psychometric properties.
Pain. 1990; 40: 171182
Nordstrom, DC, Konttinen, YT, Solovieva, S, Friman, C, and Santavirta, S.
In- and out-patient rehabilitation in rheumatoid arthritis. A controlled, open, longitudinal, cost-effectiveness study.
Scand J Rheumatol. 1996; 25: 200206
Hawk, C, Long, CR, Reiter, R, Davis, CS, Cambron, JA, and Evans, R.
Issues in Planning a Placebo-controlled Trial of Manual Methods: Results of a Pilot Study
J Altern Complement Med 2002; 8 (1) Feb: 2132
Outcome measures for assessment of treatment of the dizzy and balance disorder patient.
Otolaryngol Clin North Am. 2000; 33: 519533
Jacobson, GP and Newman, CW.
The development of the Dizziness Handicap Inventory.
Arch Otolaryngol Head Neck Surg. 1990; 116: 424427
Wall, J, Lichtenberg, P, MacNeill, S, Walsh, P, and Deshpande, S.
Depression detection in geriatric rehabilitation: Geriatric Depression Scale short form vs long form.
Clin Gerontol. 1999; 20: 1321
Ready, A, Naimark, B, Tate, R, and Boreskie, S.
Fitness centre membership is related to healthy behaviours.
J Sports Med Phys Fitness. 2005; 45: 199207
Adams, P and Schoenborn, C.
Health behaviors of adults: United States, 2002-04.
Vital Health Stat 10. 2006; : 1140
Kaufman, D, Kelly, J, and Rosenberg, L.
Recent patterns of medication use in the ambulatory adult population of the United States: the Stone Survey.
JAMA. 2002; 287: 337344
Return to SENIOR CARE
Return to VERTIGO and BALANCE